Inspection on 23/07/09 for Littledene House

This inspection was carried out on 23rd July 2009.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Littledene House 16/12/09

Littledene House 30/05/09

Littledene House 05/05/09

Littledene House 08/04/09

Littledene House 12/11/08

Littledene House 30/04/08

Littledene House 16/05/07

Littledene House 06/09/06

Littledene House 17/02/06

Littledene House 08/08/05

Littledene House 17/12/04

Littledene House 30/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for older people Name: Address: Littledene House 54 Bushey Grove Road Bushey Hertfordshire WD23 2JJ     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Patricia House     Date: 2 3 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Littledene House 54 Bushey Grove Road Bushey Hertfordshire WD23 2JJ 01923245864 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: m.ang@btopenworld.com Ms Margaret Ang care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: If the names service user ceases to be accomodated at the home then the variation to the category shall cease. The home may accommodate one named service user under the age of 65 with Dementia. The manager must inform CSCI if the service user permanently leaves the home for any reason. Date of last inspection Brief description of the care home Littledene House is a care home providing personal care and accommodation for twelve elderly people who may also have a dementia. Littledene is privately owned and the proprietor also manages the home. The property is a large detached house, which has been converted to provide single room accommodation. Six of the bedrooms have en-suite toilets. The house is well Care Homes for Older People Page 4 of 39 Over 65 12 12 1 0 0 5 0 5 2 0 0 9 Brief description of the care home presented and provides residents with comfortable surroundings in a homely atmosphere. There is a passenger lift for easy access to the upper floor and an enclosed garden to the rear. The frontage of the property is attractively paved and allows for the parking of several cars. A single storey extension at the back of the house provides living accommodation for three members of the care staff. Littledene is situated in a quiet residential road in the village of Bushey and is approximately two miles from the village High Street and also about two miles from the extensive amenities of Watford Town. There are local shops a short walk away. There are nearby bus and rail services and the home is close to several major roads and motorways. Current charges for the home range from £500.00 to £580.00 per week. Further information can be found in the homes Statement of Purpose and the Service Users Guide, which are displayed in the entrance hall. The home also has an internet web site. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection of this service took place on 17th November 2008. Since that time random inspections of the home have taken place on 8th April, 5th May and 28th June 2009. A Statutory Requirement Notice was also served on the proprietor on 1st June 2009. The information in this report is based on an unannounced inspection of the home, which took place over one day with two regulation inspectors carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as we. The registered manager was on duty throughout the day and we spoke with staff and residents. We observed a visiting activity provider during the day. We visited all parts of the home and checked a variety of records. We also removed some documents from the home using the Commissions statutory powers. Care Homes for Older People Page 6 of 39 There is an on-going investigation in progress, co-ordinated by Hertfordshire County Council under the joint agency safeguarding vulnerable adults procedures. Two additional strategy meetings have also been held by the Local Authority to consider issues at the home. We have also reviewed any other information we have received about this service since the last key inspection. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? The improvements made since the last key inspection are as a direct result of our inspections and the requirements and recommendations made. The manager has reviewed and updated residents plans but more work is needed to ensure all individual needs are recorded together with the corresponding management plans to show how to meet these needs. However care plans have now been signed by residents or their families. Medication is being appropriately administered so that peoples health is safeguarded. Care staff have received updates of training about maintaining residents dignity and providing people with choices in all areas of the home. We saw residents provided with choices about when to get up and when to eat their meals. Care staff confirmed that incontinence care now ensures that no residents have wet beds in the morning. Residents have their own toiletries stored in their bedrooms so that they do not have to share communal items. Care staff provided some activities during the visit and plans for daily activities are displayed for the enjoyment of the residents. We noted during the visit that several residents appeared more animated than at previous inspections. External entertainers also visit the home now including a reminiscence provider and musicians. The home now has a wide range of equipment aimed at meeting the needs of people who are confused. We saw a rotunda standing aid appropriately used and all care staff demonstrated an awareness of safe handling procedures when they spoke with us. The manager is continuing to provide a range of training courses for staff to ensure their competency and two care workers have started NVQ2 training. A staff meeting has taken place and we found that the staff on duty were working as a team and supporting one another and were clear about the improvements they were trying to achieve. The care staff have clearly worked extremely hard to make real improvements to the day to day running of the home and the residents have benefitted from these efforts. Care Homes for Older People Page 8 of 39 Procedures for preventing the spread of infection in the home have improved. Staff now have disposable gloves and aprons available and there are bins with lids for incontinence aids and laundry carriers have been provided. All communal bathrooms and toilets have liquid soap and paper towels available. The manager has made complaints forms and quality surveys available to visitors so that everyones views about the home can be considered. A residents meeting has also been held and minutes taken to ensure the home is meeting peoples current needs. Care staff now have contracts of employment and receive pay slips for their pay. A new care worker had been appropriately recruited and was undergoing thorough induction training. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 9 of 39 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 39 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 1, 3 and 4. Standard 6 does not apply to this home. People who use the service are provided with written information about the home and have their needs assessed so that all parties can be sure that the home is right for them and that staff can meet any specialist needs they might have. Evidence: We saw written information about the home displayed in the entrance hall. A residents charter is displayed on the wall and there are copies of the homes Statement of Purpose and Service Users Guide on the hall table. The information about the staff team is no longer accurate in these documents. No Commission inspection reports are displayed. The written information must be brought up to date and the inspection reports made available so that people who use or intend to use the service have accurate information provided so they can decide if the home is the right place for them. The manager said the information would be updated and reports made Care Homes for Older People Page 12 of 39 Evidence: available. We have checked the care records of people living in the home at recent previous inspections and checked a selection of plans on this occasion, although no new people have moved into the home this year. This is because the Local Authority have ceased to make any new placements while the current safeguarding procedures remain ongoing. All plans contain written copies of original needs assessments and the information had been used to complete initial care plans so that all parties could be clear about individual needs and how to meet them. Most of the current residents in the home have a level of confusion or dementia or need care taken to ensure staff communicate with them effectively. Specialist staff training is therefore needed to ensure all residents needs can be met. Current care staff have completed basic dementia care training apart from three and we saw a notice displayed that these three people were due to have this training provided the day after the inspection. The manager has completed an advanced dementia care course and the certificate for this was seen. However the manager had been unable to attend a course she had booked for training in Therapeutic Activities in Dementia Care. The manager confirmed that an activity organiser who visits the home, but is not employed by the manager, completed the course instead and visits the home regularly to provide dementia and reminiscence activities. This persons photograph is displayed with those of other staff members in the entrance hall. We saw a wide range of equipment to be used for dementia activities in the home and appropriate displays of images linked to reminiscence in all communal areas. We did not see any employed care staff provide any specialist activities. There are now signs and pictures on all bedroom, bathroom and toilet doors to assist residents to find their way and remain as independent as possible. There are currently two non-English speaking residents living at the home. There are some signs in their own language displayed in appropriate places and the manager also speaks their language. The completed AQAA returned to the Commission from the manager said an implementation plan for dementia care had been developed for the home. However we saw no evidence of this. We could not establish at this inspection that the manager fully understands the wider concept of dementia care provision or is researching current guidelines for providing good specialist care but the manager is aware that further planning would be needed if more confused people move into the home. Subsequent to the inspection the manager has provided the Commission with a copy of the homes development plan for providing services aimed at people with a dementia. This plan should now form the basis of future service provision at Littledene. Care Homes for Older People Page 13 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 7, 8, 9 and 10. The needs of people who use the service are documented but more detail is needed so that all their needs can be identified and met. The homes system for administering medication is thorough and helps to promote residents good health. Evidence: During the inspection we observed the staff interaction with residents and asked questions of staff about the care they provided. The interaction with staff was meaningful and the care we saw staff provide was good. The care staff said they are aware of and read residents care plans but only the manager and one named member of staff write in the plans. However care staff write details of the care provided for each resident in a daily log and we examined this log book. Staff had recorded information in detail and had provided a clear picture of each residents daily care. The staff members we spoke with said they are told by the manager about each residents care needs and of any changes and, because there are only 7 residents in the home at present, they all know what each resident needs, without looking at the care plans. Care Homes for Older People Page 14 of 39 Evidence: However, when more people are living in the home it will be essential that all care plans set out the detailed needs of each resident and how these needs are to be met in the home, as there will be less time available to ensure that all staff hear and understand details about any changes if information is only passed verbally. In addition, care plans must now centre on the person concerned and provide background information about each individual and set out the aims and choices agreed with the resident or their representative. This is important so that all staff know why someone has made a choice and can provide individualised care to meet the persons needs. This information can only be set out clearly in a written plan. The care plans we checked during the visit are fairly detailed but do not all provide sufficient detail of individual needs although some life histories have been completed and residents have signed the plans. We also saw a recent note on one plan, written by the manager and signed by the resident that the resident had had the care plan explained to them and wanted the plan discussed and reviewed in another six months. The manager has added recent notes about residents choices to other existing plans but needs to restructure the plans to ensure everyone is clear about the individual concerned. Where people are confused and making significant choices about their care it can also be appropriate to involve an advocate who can independently verify any choices made and this involvement should be considered for the future. It is acknowledged that the present residents have lived in the home for a number of years and may not be interested in making new statements about their care and some families may not see this as necessary. However, if the home is to accept new residents new forms of care planning should be introduced so that individuals can live an enjoyable life in a way they choose. The manager confirmed she is booked on a training course for Person Centred Planning, which will start in February 2010 and will review the care plan format as soon as possible. The current care plans we checked were fairly detailed and generally reflected the needs of the people we had seen or spoken with. Where we had not seen an accessible call alarm in a residents bedroom information had been recorded in the relevant plan why this was so. However some plans needed more detail to ensure appropriate care is always provided. We observed one resident in the early morning who was sleeping on a Kylie incontinence sheet with just a cellular blanket covering half of them. Both windows in the room were wide open. The manager said this was how the resident chose to sleep but this information was not recorded in the sleep section of the care plan. There are currently three residents in the home who have diabetes. It was clear from the daily log records and the records of food eaten that these people do eat quite a lot of biscuits and cakes as snacks which can be detrimental to some diabetics. In one care plan an entry says that no sugar should be added to the food prepared but the manager has also made a recent note that the resident has chosen to eat the sugary foods described. There were no clear instructions to staff about how to meet the nutritional needs of the residents in Care Homes for Older People Page 15 of 39 Evidence: question and no associated risk assessments completed but we saw evidence that district nurses now monitor the residents glucose levels monthly. However on one care plan we saw a letter from the G.P. that a resident with diabetes should have their eyes tested annually because of the risks associated with the condition, but saw no evidence that these checks have taken place. In another care plan we saw evidence that the resident had been referred to and assessed by a Speech and Language specialist. A soft diet with meat pureed was recommended in writing by the specialist and detailed information about soft diets was provided. However the records of food eaten by the resident showed no evidence that all meat was pureed or that all the meals provided were soft. Details showed that food such as meat pie and meat burgers were given and during the inspection part of the residents dinner was a quiche with pastry. A member of the care staff said that the resident now ate normal food and did not need all the meat pureed but this was not clarified in the care plan and could cause confusion for staff and have a possible detrimental affect on the resident. The manager had made a recent note in two other plans that the residents in question did not want to wear underwear as they wanted to be comfortable. This followed comments made by a district nurse at a multi-agency meeting that some residents did not wear underwear. The residents concerned had signed these entries but we saw no details of when this choice had been made or whether families or representatives had been made aware of this. There appeared to be some confusion about the night time wishes of one resident. Care staff told us the resident was anxious at night and liked their doors left open but the manager said the door was closed. There were no entries in the care plan to clarify this. Care staff also confirmed that two residents were turned or repositioned at night and the daily log showed this was happening. However the care plan we checked had no detail that this night task was part of the residents planning. We saw some risk assessments completed in the care plans checked including those for assisting residents with transfers. Some of the risk assessments we saw in residents care plans were over three years old and needed replacing or updating although an entry of no change had been made in most cases. Falls assessments of risk levels had been completed for all residents but where the risk had been assessed as high no detailed assessments of the situation or management plan had been completed to ensure the resident was as safe as possible. It had also been established at a multi-agency meeting that a lap belt should be used when a named resident was moved in a wheel chair as the person was anxious about this transfer. We saw no entry about this use on the residents care plan and saw the resident moved with no belt in place until we asked staff to use this safety aid. The manager had also been advised at the meeting that staff should no longer use a handling belt for certain residents but this aid was still forming part of the moving plan on the care plans we Care Homes for Older People Page 16 of 39 Evidence: checked. Quality surveys returned to the Commission from two G.P. surgeries indicate that the doctors who visit the home have no concerns about the care provided. District nurses currently visit the home twice each week and dress the legs of one resident during these visits. Details in the residents care plan state that their legs should be kept elevated at all times and we have seen the individuals legs appropriately raised on each visit to the home. Some of the arm and dining chairs in the home have special cushions in place for residents who need pressure relief and there is a hoist available in the home, which staff confirmed is currently used to transfer two residents. However the space in the bathroom is very limited and care staff confirmed that they cannot easily assist the people to bath who need a wheel chair and a hoist for transfers. During a previous visit we saw unsafe practice taking place in the bathroom when a hoist was used and the manager is aware that this situation is not acceptable. The possible outcome for dealing with the current difficulty is that care staff could find it easier to lift the resident concerned, which could put both the resident and staff concerned at risk of harm. We saw staff assist another resident to transfer using a rotunda standing aid. The transfer was completed appropriately to ensure the residents safety. One resident has their own wheel chair and there is an additional wheel chair available in the home. We saw both used appropriately during the inspection. Care staff confirmed that only district nurses now test the blood sugar levels of residents in the home. We spoke with several care workers and all confirmed that there were two residents who were turned or repositioned during the night. We saw details of this care recorded. We also saw written details of the personal care provided daily for every resident. During the inspection one resident was taken by ambulance for a hospital appointment and one member of staff accompanied the individual to ensure they were comfortable about the visit and could understand any outcomes. We checked the system for the administration of medication in the home. Most medication is provided in sealed blister packs. There are four drugs rounds each day and all staff are trained to provide medication to residents. The home has a dedicated medication fridge which we saw was kept locked and staff were appropriately storing and recording the small amount of controlled drugs which one resident is prescribed. We spot checked one box of non-blistered medication and all amounts tallied. We checked the homes written medication policy. This is appropriate and comprehensive but just needs the addition of the homes procedures for training staff and checking their competencies to ensure that all staff involved in the process operate a safe system for the benefit of the residents. Care Homes for Older People Page 17 of 39 Evidence: We spoke with care staff during the visit and all confirmed that they had had recent meetings in the home where discussions and directives about ensuring the privacy and dignity of residents took place. Care staff were clear about what these concepts meant in practice and gave us examples of how they ensured everyone was treated with respect and in a way they preferred. We saw good practice taking place during the visit. Care Homes for Older People Page 18 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 12, 13, 14 and 15. People who use the service enjoy a range of activities which help them to enjoy their daily lives and are provided with appropriate meals which help to ensure their well being. Evidence: During the inspection we saw the activity plan displayed and this showed that activities were provided from Monday to Saturday. However the staff we spoke with said that they provide activities on a daily basis when they have finished their jobs and they ask the residents what they want to do, so the plan is not always followed. Some of the activities provided are shown as soft music, cards, Mah Jong, dominoes, word search and chatting individually. On the morning of the inspection one resident was playing dominoes and another resident was looking at photographs with the manager. We were told by staff that outside entertainers also visit the home and the manager states that a violinist comes every week. An external activity provider who provides reminiscence therapy with the residents visited the home during the inspection and spent time in discussion with one resident. We saw good interaction between the staff and residents and some staff lead the residents in a karaoke sing Care Homes for Older People Page 19 of 39 Evidence: along in the afternoon. The level of activities provided has greatly increased since the last key inspection and several residents appeared quite animated during the day. We did wonder if the visual stimulus of mainly 20th century English memorabilia would have any meaning for the two Chinese residents or whether these people had access to any appropriate reminiscence material. The television programmes shown would also have limited meaning for these two residents who speak no English. However the manager has stated that these two Chinese residents have expressed very little interest in reminiscence activities and have details of their agreed social care needs recorded in their care plans. We saw the activities people take part in recorded in daily records and these records confirmed that some events take place each day. Two of the current residents are unable to participate in these activities and spend their days in recliner chairs. We saw staff talking with these people during the day and both had quiet music provided for them. We saw no evidence that any trips out take place although one resident has walked out of the home on their own in the past. One resident also attends a day centre once a week. We saw the minutes of a recent relatives meeting which had been held at the home. Family members for two of the residents took part in this, together with the manager. The minutes show that the relatives thought that going out of the home might be too confusing for the residents so it was best for them to stay in the home. It should be remembered that only two families took part in this meeting and to ensure that residents are all able to make informed choices about outings the introduction of an advocate into the home should be considered, as already noted. Currently none of the staff at the home have attended mobility and exercise training, which aims to enable staff to provide residents with appropriate physical exercise so they can maintain their mobility. The manager said she had been booked on a training course in mobility and exercise but would not now be able to go on this course. It did not appear that any of the remaining staff would be sent instead, which is a pity as as this training would have been of direct benefit to residents. The staff we spoke with said that relatives and visitors were welcomed in the home at all times and visitors who have returned surveys to the Commission in the past have confirmed this. As already noted, care staff have had recent discussions with the manager to ensure that residents are provided with choices about how they spend their days. We arrived at the home just after 7am and saw some residents already up while we noted that others did not get up until after 9.30am. Breakfasts were provided at differing times, when residents were ready for this meal. The care staff we spoke with confirmed they did not wake anyone up to fit in with a prescribed routine. We also spoke with a new Care Homes for Older People Page 20 of 39 Evidence: member of staff who confirmed that providing meaningful choices is now a part of the induction training at the home. The manager confirmed that she continues to purchase all toiletries for residents, none of whom hold their own personal allowances. From the minutes of the relatives meeting we saw that the families concerned had confirmed that this procedure was acceptable. This area could again be considered by an external advocate as, even if current residents do not want to purchase their own goods, future residents might want this option. We saw that the front door of the home is locked with a key which is held by the senior on duty. The back gate of the home is also kept locked. The manager said that she had checked that this procedure was acceptable under the Mental Capacity Act as people in the home did not have the capacity to go out of the home unaccompanied. However, monitoring should take place and if it is seen that any resident wants to go out, this choice would have to be accommodated. The door locking situation will have to be revisited as new residents enter the home. When we arrived at the home we saw the dining tables set for breakfast with a choice of cereal and two choices of juice. We did not see anyone actually choose from the choices on the tables, as care staff brought the different breakfasts straight from the kitchen, although they asked what was wanted first. The breakfast menu displayed showed that a cooked breakfast was offered on a Wednesday, and the food records we saw confirmed this. The daily menu was displayed and we saw that there was a three week rolling menu in operation. Care staff showed us the excellent pictorial menus which had been produced so that even the confused residents can be clear about the food which could be chosen. There is an alternative choice of food offered at each meal time and this choice is also displayed. We saw the dinner served during the inspection and this was served hot and was clearly enjoyed by the residents. There was a relaxed atmosphere during the meal and people enjoyed their food at their own pace. We saw staff offer tea and coffee to residents after the meal. We saw the completed records of the food eaten daily by residents and saw evidence that snacks and drinks are offered to people in the evening. We saw a basket of fruit and crisps in the kitchen and the manager said this was taken round by staff at various times of the day so that residents could have a snack when they wished. The fridge and freezer were well stocked with food and we saw good supplies of fresh milk and juice. Care Homes for Older People Page 21 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 16 and 18. People who use the service are aware of how to voice any complaints they might have but cannot be sure that all procedures followed in the home will protect them from the risk of abuse. Evidence: The home has written policies covering making a complaint and whistle blowing. Complaint forms are available in the entrance hall, but, as already stated, it is good practice to display a copy of the policy so that visitors and residents can be sure of the system and feel comfortable making a complaint. All but one of the care workers we asked said they had seen the policy and were aware of the procedure and all were aware of whistle blowing procedures. We saw the homes complaint record book but no complaints had been made. No complaints have been made to the Commission about the home since the last inspection. The care staff we asked all said they had received safeguarding training. They demonstrated a good understanding of the concepts involved and the associated procedures. Three members of staff had not had safeguarding training yet but we saw evidence that these care workers were booked on this course the following day. Since the inspection we have been told that one of the three did not take part in the training and the manager must ensure that this individual completes this training as soon as Care Homes for Older People Page 22 of 39 Evidence: possible. We checked the homes written safeguarding policy during the visit. This just needed some amendments to clarify the procedures linked to investigations so that local joint agency procedures are always followed. Currently there are two on-going investigations taking place about the home under the Hertfordshire County Council joint agency safeguarding procedures. One investigation is considering the implications of a recent visit to the home by a film crew. During the inspection we did not see evidence that the manager had obtained sufficient safeguards and details about this visit and it could not be assured that the privacy and confidentiality of all residents and visitors had been respected during filming. In addition we saw no evidence that any of the visitors had signed the homes register on this occasion and the manager could not confirm the names of all the film crew. This could have put residents at risk of harm as no evidence of peoples identity had been verified. Previous inspection visits to the home in the past year have identified serious shortfalls in staff recruitment procedures, as described in a later section. Requirements about staff recruitment were not complied with although a Statutory Requirement Notice was issued. Thorough staff recruitment procedures are necessary to ensure only suitable staff work with the vulnerable people in the home. Although the manager has now obtained the necessary recruitment evidence this was only after repeated requirements were made. The manager was not proactive in ensuring that safe practices were followed and this could have put residents at risk of harm. In addition, at the random inspection visit made on 8th April, we found that care practices in the home, seen when we visited in the early morning, were putting residents at risk of harm. We saw unsafe methods used by staff to assist residents to transfer and saw one resident left alone and at risk on an over bath seat. We also saw very poor practices in operation when staff handled soiled washing and noted that these practices continued during the day. Care staff were using one pair of household type gloves to perform all personal care tasks and confirmed they were not issued with disposable gloves, a separate pair of which should be used with each resident to prevent the spread of infection. The concerns about care practices and the very poor infection control in the home are described in detail in the report of the random inspection. As with the concerns noted above about unsafe recruitment practices, these additional practices we found in the home could have put the residents at direct risk of harm and have only ceased after requirements have been made by CQC inspectors. Care Homes for Older People Page 23 of 39 Evidence: The failure of the registered manager to pro-actively ensure safe practices are followed in the home, has resulted in this section being rated as poor in this report. Care Homes for Older People Page 24 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 19, 21 and 26. People who use the service benefit from living in a comfortable well maintained home where most procedures followed by staff help to reduce the risk of the spread of infection in the home. Evidence: During the inspection we visited all parts of the home and all areas were clean. The furniture in communal areas has been rearranged since the last key inspection and now provides more attractive and varied seating areas for residents. The walls are now covered with interesting pictures and posters and communal areas are free from clutter. One resident who was barricading their bedroom door at the time of the previous key inspection, now has an appropriate lock on their door so that they can lock the door when they choose. This lock can be overridden from the outside for safety. The home has a portable ramp for the use of residents in wheel chairs and we saw this used when a resident was taken out for a hospital appointment. During the inspection we saw some staff bags and a coat left in the dining room. Some other staff belongings are kept in the kitchen. There is no office in the home and currently no changing or storage facilities provided for the staff who do not live on the premises. The manager must provide suitable facilities for staff so that residents Care Homes for Older People Page 25 of 39 Evidence: communal areas are not used for staff storage and the kitchen is kept clear for reasons of safety. It was established at previous visits that the ground floor bathroom is not suitable for the use of residents who need a hoist to transfer. The bathroom door has to be left open when the hoist is used as space is very limited so the manager has had a curtain fitted around the door so that residents privacy can be maintained if the door is left open when they have a bath. This bathroom is assisted and the shower attachment has been replaced recently. During the inspection a contractor replaced a worn section of the bath hoist which could have presented an infection risk. The manager was advised during a recent safeguarding meeting to make a referral to an occupational therapist to get advice about bathing facilities in the home, especially where residents need a hoist to enter the bathroom. The manager has not yet made this referral but said she will be considering how to change the bathroom facilities soon. There is a second bathroom in the home which is not assisted. This bathroom/toilet is not used by residents and has a notice on the door which says Staff/visitors please lock this door when not in use. Thank you. There is a bedroom immediately next to this bathroom, which is currently empty. When a new resident is admitted to this room, it must be established whether it is appropriate that they have to come downstairs to use a toilet or bathroom rather than use the facilities next door. When the home is full residents needs must also be reassessed to determine if two assisted bath or shower rooms are needed to meet peoples needs. We saw liquid soap and paper towels in holders provided in all communal bathrooms and toilets as recommended for good infection control. Lidded bins have been provided for used incontinence aids and staff now have laundry holders for transporting washing through the home. We saw staff using disposable gloves and aprons and saw additional supplies available in areas around the home. However the staff we spoke with said that currently they use the ground floor bath to sluice off soiled laundry. Although staff said they disinfect the bath after this use, the practice is not acceptable as it presents a risk of the spread of infection. The manager must provide alternative means for sluicing soiled linen. The manager confirmed she has obtained copies of two publications previously recommended and seen as essential for providing guidance for maintaining good infection control in care homes. One resident recently returned from hospital and had a wound infected with MRSA. We saw details recorded of the procedures taken by staff in the home and of the progress of the treatment provided and saw that the care and recording were excellent. Care Homes for Older People Page 26 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 27, 28, 29 and 30. People who use the service are supported by care staff who are well trained but cannot be sure that staff are employed in sufficient numbers to meet all their needs. Evidence: We saw the staff roster for the month when we entered the home and we removed a copy from the home. On the day there were three care workers on duty and an additional care worker accompanied a resident to a hospital appointment. The staff roster showed that, apart from the manager, there are currently five permanent members of staff employed and one new recruit who is also a student and has no CRB clearance yet and so cannot work unsupervised. Of these one care worker is leaving at the end of July and currently provides minimal cover as they are pregnant. There is an additional care worker recruited who care staff told us works elsewhere, and who provides some weekend cover from time to time. Two of these care workers provide waking night cover each night. To meet the required numbers of staff on duty the manager has been working for 18 hours each day covering the late shift and nights. This has been happening on seven days each week. In addition two care workers told us that one worked 243 and one 225 hours last month and that they would have to work longer hours in two weeks time to cover the managers absence. The care staff we spoke with confirmed that none of the staff had signed an agreement to opt out of Care Homes for Older People Page 27 of 39 Evidence: the European Working Time Directive which legally limits the time anyone can work each week. Apart from the legal consideration, the hours being worked by the manager and staff must limit their ability to function properly and therefore have a detrimental affect on the care they can continue to safely provide. Care staff also provide all domestic, cooking and activity duties in the home. We also noted that the manager had made no provision to employ any additional staff to cover her work while she is away in less than a weeks time. We told the manager that additional agency staff must be employed at least while she is not working to ensure the needs and safety of residents and staff can be met. The manager confirmed that agency staff would be now be employed. Staffing numbers need to be reviewed for the long term as soon as possible. Since the inspection took place the manager has confirmed that agency staff will be employed at the home in her absence. Confirmation has also been provided that care staff have now signed the working time directive opt out clause. We checked the recruitment records of a selection of staff. One new care worker had provided a full employment history on their application form and had two appropriate references, which the manager had verified. The care worker confirmed that they were aware they could not work unsupervised yet as they had no clearance from the Criminal Records Bureau but had clearance from the Protection of Vulnerable Adults Register. Other staff now have employment contracts which show their terms of employment and rate of pay and we saw signed copies of these contracts on staff files. The manager is still awaiting evidence of permission to work in the country for some staff. However the person who visits the home to provide reminiscence activities for the residents and whose photograph is displayed in the hall way with other staff pictures, has no clearance from the Criminal Records Bureau. All people who have significant contact with any vulnerable person in a care setting must have evidence of this clearance for the protection of the residents concerned. At the last key inspection we found evidence that care staff had not been properly recruited. Since the key inspection random inspection visits have been made to the home where we found further evidence of shortfalls in recruitment practice at each visit. (Described in detail in the random reports of these visits) After each inspection report made relevant requirements the proprietor confirmed in writing that all staff would now be properly recruited. Despite this and despite a Statutory Requirement Notice being served listing recruitment requirements, we again found, at the inspection on 28th June, that a domestic worker had continued to work at the home throughout the whole period of inspections with no recruitment checks having been made. The manager had previously confirmed in writing that this person had left the Care Homes for Older People Page 28 of 39 Evidence: home. The manager must therefore continue to demonstrate a commitment to employing staff who are properly recruited so that it can be assured that residents in the home are always protected from the risk of harm. The on-going failure to provide this protection, together with the risk of insufficient staff numbers being planned for the managers absence, has resulted in this section of the report being rated as poor. We checked the staff training records and spoke with staff about their training. Two care workers confirmed they have started NVQ 2 training. We saw evidence that most staff had completed all the basic training courses considered essential to the role of care worker and almost all have completed a basic dementia awareness course. The new care worker confirmed that adult safeguarding awareness is now covered in staff induction training and that they were due to take part in courses covering abuse awareness, dementia care and infection control the following day. We are aware that the care worker employed from time to time was also due to attend this training but did not. The manager must ensure that this employee undertakes this training as soon as possible especially as we only saw one verified reference on their staff file. As already noted, there are people with diabetes living in the home and care workers should have diabetes training provided as soon as possible so that staff can understand how best to meet such peoples needs. Care Homes for Older People Page 29 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 31, 33, 35 and 38. People who use the service are now able to feel confident their views will be listened to but will need more time to be sure the home will continue to be run in their best interests. Evidence: Thirty-one requirements were made as a result of the key inspection in November 2008. These shortfalls, covering all areas of care home provision, demonstrated that the manager had not been pro-active in maintaining good standards of care provision for people who use the service. Since that time the manager has endeavoured to comply with the requirements, as noted in this report. However, there are still important areas where the manager has failed to operate good practice. It is therefore not clear that the manager will be proactive in providing a service where the quality of life for residents in the home is always considered and improved or where new guidelines for providing care are researched and implemented, unless these outcomes Care Homes for Older People Page 30 of 39 Evidence: are required by an outside agency. The manager had not been aware, until informed at a CQC meeting, that people such as the external reminiscence activity provider need clearance from the Criminal Records Bureau to ensure the safety of residents. The manager was not aware that care workers must agree and sign an opt out declaration if they are to work excessive hours. These legalities have been made public for some years and the manager should have been aware of and adhering to them. In the report of the November inspection we noted and made requirements that thorough recruitment procedures must be followed in the home to ensure residents are not put at risk of abuse. Despite this the manager continued to employ staff who were not adequately recruited. The manager responded in writing that she was complying with this essential requirement but despite this and despite a Statutory Requirement Notice being served, the manager still employed a member of staff with no recruitment checks made. At this inspection visit we have shown that staff were working excessive hours and that the manager had not attempted to use agency staff to ensure that staff worked a safe number of hours each week. Agency staff cover has only been sought as a result of our advice. Similarly, until requirements were made, there had been poor practice in the areas of respect, dignity and autonomy of residents, providing negative outcomes for some of them. Also, until the omissions were highlighted the manager had been failing to notify the Commission and the Local Authority about significant incidents affecting residents, although this information was a statutory and contractural requirement. The shortfalls found in management procedures are not surprising as the manager has not remained supernumerary to care staff, so that her management duties could be fulfilled, but has worked 18 hours each day as a care worker rather than employ more care staff. In addition the computer and fax machine for the service are kept in the managers home. This means that to research and find essential information or send information to other agencies the manager has to leave the home, thus reducing staff care cover. As a registered nurse the manager must have been aware of what is considered good practice for infection control, but ran the home in direct contravention of these guidelines and put residents at risk of harm. It is acknowledged that most of the 31 requirements made in November have now been met, that the care provided for the current seven residents is good and that the ethos of the home has been positively revamped. However it needs to be established that the improvements will be maintained and that a new staffing structure will allow Care Homes for Older People Page 31 of 39 Evidence: the manager to fulfill her statutory role and be pro-active in maintaining good standards of care for the people who use the service before more people move into the home. The manager will need to demonstrate a development plan for the home and provide timescales so that all parties can be clear about the homes future. The care staff we spoke with confirmed that a staff meeting had taken place two weeks ago. We were shown the minutes of this meeting. The staff also said that the manager now listened to all staff views and that all staff now have individual supervision. We saw supplies of visitors and relatives quality surveys and complaints forms available in the hall for any one to complete so that visitors could make their views known. We also saw a Comments and Compliments book in the hall. There were eight entries in this, all making positive comments. As already noted the manager has also started holding meetings for relatives and we saw the minutes of a recent residents meeting. We saw some completed residents questionnaires on their care records. All forms recorded positive comments and had been signed by the resident although completed by staff. We saw the homes written Quality Assurance policy but this was a general document and needed details added of the quality monitoring arrangements relating to the home, which have clearly been started by the manager. We checked the homes fire safety records and these were in order. The homes fire alarm was tested during the inspection. Staff confirmed they have received fire safety training and we have received information from a fire safety officer that the fire safety system and equipment at the home are in order. We checked the homes accident records and details had been appropriately recorded. We saw no First Aid box in the home during the inspection and the two care staff we questioned said they were not aware of such equipment in the home. The manager said there was a First Aid box, kept in a cupboard with the nurses supplies. This equipment must be made available to all people in the home and the contents must be audited regularly so that any accidents can be dealt with quickly and appropriately. One member of staff said they were not aware of where to find the homes written policies but the new care worker confirmed they had been given the policies to read. The manager said she would ensure all staff were made aware of the policies and their contents. We checked the written policies during the visit and, as already stated, found the homes policies on Medication Administration, Complaints and Safeguarding thorough and only needing some small updates. However the Infection Control policy is not adequate and does not provide clear procedures for staff to follow. The manager also needs to update the policy on Restraint in line with current Department of Health guidelines. The home also needs a detailed Health and Safety policy and statement Care Homes for Older People Page 32 of 39 Evidence: which includes generic risk assessments for the home. As already noted the manager holds no money for residents in the home. Care Homes for Older People Page 33 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 All residents in the home must have a written plan which details all their needs and shows how these needs are to be met in a Person Centred way. The timescale for this requirement was not met. A new timescale has been made. This is so that all residents are supported by staff in a way that reflects their personal wishes and goals. 01/10/2009 2 7 15 The care for each resident must be regularly reviewed and documented in detail in their care plan. The timescale for this requirement was not met. A new timescale has been made. This is to ensure that all staff are aware of the current needs of the resident and aware of how these needs are to be met. 01/10/2009 3 18 13 All staff at the home must complete up to date training in Adult Safeguarding and Whistle Blowing and must demonstrate their 18/09/2009 Care Homes for Older People Page 34 of 39 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action understanding of these topic. The timescale for this requirement was not met. A new trimescale has been made. This is to ensure that people living at the home will be protected from harm and abuse. 4 31 13 The manager must ensure that appropriate written policies and procedures are in place and that these are reviewed and kept up to date. The timescale for this requirement was not met. A new timescale has been made. This is so that staff especially are aware of procedures to be followed for the benefit of all parties in the home, and to ensure the safety of residents. 01/10/2009 Care Homes for Older People Page 35 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 18 12 Detailed information must be 21/08/2009 provided before anyone is allowed to film at the home and staff must ensure that any connected visitors are appropriately supervised at all times. This is to ensure the privacy and safety of all residents in the home. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 Provision must be made for staff changing and storage facilities. This is so that no areas of the home presents a hazard to residents and so that the belongings of care staff are kept safe. 01/10/2009 2 21 23 A review of bathroom facilities in the home must be made. This is so that the bathing needs of all residents can be safely met in the home. 01/10/2009 Care Homes for Older People Page 36 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 26 23 Appropriate sluicing facilities 01/10/2009 must be provided in the home. This is so that good infection control can be maintained in the home. 4 27 18 Sufficient numbers of staff must be employed and appropriately deployed in the home at all times. This is so that residents needs can be safely met at all times. 31/08/2009 5 29 19 All people who provide 30/10/2009 services and have significant contact with residents in the home must provide clearance from the Criminal Records Bureau before their duties commence. This is so that residents are protected from the risk of harm. 6 30 18 Diabetes training must be provided for all staff at the home. This is so that it can be assured that the needs of people with diabetes can be safely met at all times. 30/10/2009 7 37 17 Appropriate records must be 21/08/2009 kept of all visitors to the care home. Care Homes for Older People Page 37 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that no resident is put at risk of harm. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 38 An appropriately equipped first aid box should be available in the home at all times. This is to ensure the safety of all people in the care home. Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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